Dose-dependent effects of red blood cell transfusion and case mix index on venous thromboembolic events in spine surgery

Brian D. Lo, Omar Qayum, Kristen K. Penberthy, Richard Gyi, Laeben C. Lester, Nadia B. Hensley, Daniel M. Sciubba, Steven M. Frank, Brian C. Cho

Research output: Contribution to journalArticlepeer-review


Background and Objectives: Venous thromboembolic (VTE) events represent a major source of morbidity and mortality in spine surgery. Our goal was to assess whether a dose–response relationship exists between red blood cell (RBC) transfusion and postoperative VTE events among spine surgery patients. Materials and Methods: A total of 786 spine surgery patients at a single institution who received at least 1 RBC unit perioperatively were included (2016–2019). Patients were stratified based on RBC transfusion volume: 1–2 units (39.3%), 3–4 units (29.4%), 5–6 units (15.9%) and ≥7 units (15.4%). Subgroup analyses were performed after stratification by case mix index, a standardized surrogate for patients' disease severity and comorbidities. Multivariable regression was used to assess risk factors for the development of postoperative VTE events. Results: The overall VTE event rate was 2.4% (n = 19). A dose–response relationship was seen between RBC transfusion volume and VTE events (1–2 units: 0.97%, 3–4 units: 1.30%, 5–6 units: 3.20%, ≥7 units: 7.44%; p < 0.01). Similar dose–response relationships were seen between case mix index and VTE events (1.00–3.99: 0.52%, 4.00–6.99: 2.68%, ≥7.00: 9.00%; p < 0.01). On multivariable regression, larger RBC transfusion volumes (adjusted odds ratio [OR] 1.18 per RBC unit, 95% confidence interval [CI] 1.07–1.29; p < 0.01) and higher case mix index scores (adjusted OR 1.39 per unit increase, 95% CI 1.14–1.69; p < 0.01) were associated with an increased risk of thrombosis. Conclusion: Larger RBC transfusion volumes and higher case mix index scores were associated with an increased risk of VTE events. Physicians should be aware of how these dose–response relationships can influence a patient's risk of developing thrombotic complications postoperatively.

Original languageEnglish (US)
Pages (from-to)76-83
Number of pages8
JournalVox sanguinis
Issue number1
StatePublished - Jan 2023


  • red blood cell
  • spine surgery
  • transfusion
  • venous thromboembolic events
  • venous thromboembolism prophylaxis

ASJC Scopus subject areas

  • Hematology


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